Healthcare Provider Details

I. General information

NPI: 1952599409
Provider Name (Legal Business Name): CANYON MEDICAL GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/10/2007
Last Update Date: 01/23/2023
Certification Date: 01/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1624 N 200 E STE 160
LOGAN UT
84341-3175
US

IV. Provider business mailing address

1624 N 200 E STE 160
LOGAN UT
84341-3175
US

V. Phone/Fax

Practice location:
  • Phone: 435-750-5599
  • Fax: 435-750-0861
Mailing address:
  • Phone: 435-750-5599
  • Fax: 435-750-0861

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0708814
License Number StateUT

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier528291883001
Identifier TypeMEDICAID
Identifier StateUT
Identifier Issuer

VIII. Authorized Official

Name: WENDY WIMMER
Title or Position: MANAGER
Credential:
Phone: 435-750-5599